Efficacy and Safety of CT-Guided Kidney Biopsy for the Diagnosis of Glomerular Diseases in Complicated Patients

INTRODUCTION

Kidney biopsy is the cornerstone for the diagnosis of glomerular diseases and to guide treatment. Percutaneous ultrasound-guided kidney biopsy is currently the gold standard to obtain cortical specimens. However, in cases where ultrasound-guided kidney biopsy is not deemed safe (obese patients, deep kidneys, or kidneys with a complicated anatomy), CT-guided kidney biopsy could be a convenient alternative to obtain renal tissue samples. The aim of this study was to describe the diagnostic yield and complications of CT-guided kidney biopsies in patients with glomerular diseases that were previously discarded for ultrasound-guided kidney biopsy.

MATERIAL AND METHODS

We performed a retrospective, single-center, observational study including patients who underwent CT-guided native kidney biopsies in our center after being contraindicated for ultrasound-guided biopsy. Patients' records were reviewed retrieving baseline characteristics and pre-biopsy clinical, laboratory parameters and concomitant medication. The biopsy needle gauge, site of puncture, and number of needle passes were recorded. The diagnostic yield was evaluated by the number of glomeruli obtained, the rate of specimens that were adequate to reach diagnosis, and the number of biopsies that had to be repeated. Complications were defined as minor (hypotension, hematoma) and major (arteriovenous fistulae, major bleeding requiring embolization, or nephrectomy). The diagnostic yield and complications were compared to ultrasound-guided native kidney biopsies performed during the same period.

RESULTS

56 CT-guided native kidney biopsies were performed during the study period. The number of glomeruli obtained per patient was 11.5 ± 6.3, which was inferior to that obtained from ultrasound-guided biopsies (14.08 ± 8.47, p < 0.05). However, the rate of specimens that were adequate to reach a diagnosis was similar (92.9% vs. 90.8%, p = 0.437). The number of needle passes was higher in CT-guided kidney biopsies (2.0 ± 0.7 vs. 1.7 ± 0.5, p < 0.05), as well as the incidence of post-biopsy perirenal asymptomatic hematomas (66.1% vs. 24.5%, p < 0.01). There were no significant differences in other post-biopsy minor complications (1.8% vs. 2.5%, p = 0.621). There were no major complications after CT-guided kidney biopsies.

CONCLUSIONS

CT-guided percutaneous kidney biopsy is a valid alternative for the diagnosis of glomerular diseases in patients with special characteristics such as obesity or deep kidneys that contraindicate ultrasound-guided biopsy. In this population, CT-guided kidney biopsies are safe and provide a high diagnostic yield, reaching a diagnosis in >90% of patients that had been previously discarded for ultrasound-guided biopsy.

Epidemiology of Fabry disease in patients in hemodialysis in the Madrid community

This study screened for Fabry disease (FD) in patients in hemodialysis (HD) in the region of Madrid (CAM) with a cross-sectional design to evaluate HD-prevalent patients, followed by a three-year period prospective design to analyze HD-incident patients.

INCLUSION CRITERIA

patients older than 18 years on HD in the CAM, excluding patients diagnosed with any other hereditary disease with renal involvement different from FD, that sign the Informed Consent (IC).

EXCLUSION CRITERIA

underaged patients or not agreeing or not being capable of signing the IC.

RESULTS

3470 patients were included, 63% males and with an average age of 67.9±9.7 years. 2357 were HD-prevalent patients and 1113 HD-incident patients. For HD-prevalent patients, average time in HD was 45.2 months (SD 51.3), in HD-incident patients proteinuria was present in 28.4%. There were no statistical differences in plasmatic alpha-galactosidase A (α-GAL-A) activity or Lyso-GL-3 values when comparing HD-prevalent and HD-incident populations and neither between males and females. A genetic study was performed in 87 patients (2.5% of patients): 60 male patients with decreased enzymatic activity and 27 female patients either with a decreased GLA activity, increased Lyso-Gl3 levels or both. The genetic variants identified were: p.Asp313Tyr (4 patients), p.Arg220Gln (3 patients) and M290I (1 patient). None of the identified variants is pathogenic.

CONCLUSIONS

76% of HD Centers of the CAM participated in the study. This is the first publication to describe the prevalence of FD in the HD-population of a region of Spain as well as its average α-GAL-A-activity and plasmatic Lyso-Gl3 levels. It is also the first study that combines a cross-sectional design with a prospective follow-up design. This study has not identified any FD patient.

Why does transcultural consultation matter?

Introduction

Psychiatrists should be aware of the new challenges and needs that globalization poses.

Objectives

To highlight the need for a culturally sensitive approach to mental health.

Methods

Non-systematic review of “cultural consultation” on PubMed.

Results

Most people assume a direct connection between pathophysiology and clinical symptoms. However, evidence shows that the translation of pathophysiology and psychopathology into specific symptoms is mediated by cognitive processes and social interactions, which reflect models/practices specific to our culture. Patients focus on specific aspects of being sick, reinforced by cultural narratives or to fit expectations. Thus, people from different cultural backgrounds might have trouble communicating; cultural idioms of distress can be misinterpreted. The role of structural violence bestowed upon cultural minorities, which leads to discrimination and social exclusion, has extensively been studied as a risk factor for mental illness. Furthermore, ignoring cultural differences and diversity has been shown to contribute to healthcare disparities, hampering access to care and diminishing the quality of care received. In Canada, the Cultural Consultation Model provides cultural expertise, either by evaluating patients (preferably accompanied by the referring doctor, a translator and cultural mediator) for 1-3 sessions, providing recommendations to the referring doctor; or providing consulting to a referring doctor or organisation, through general guidance or discussion of specific cases.

Conclusions

In an evergrowing globalization process, we will inevitably have more contact with patients from culturally distinct backgrounds. To provide the best care, we must be aware of the ways in which culture can shape symptom expression, and take into account cultural explanations and preferences.

Disclosure

No significant relationships.

Systematic review of racial and ethnic disparities pertaining treatment in mental healthcare amongst incarcerated patients

Introduction

Research has shown that ethnic/racial minorities have a higher risk of homelessness, involvement with the criminal system, psychiatric misdiagnosis, treatment delay, and being prescribed first (versus second) generation antipsychotics.

Objectives

To investigate if the disparities found in the community are replicated in incarcerated patients.

Methods

Systematic review on PubMed for articles that fulfilled criteria for 4 domains: prison, psychosis, race/ethnic, and treatment.

Results

Forty-one articles matched the search criteria. Of those, 24 were irrelevant; 2 were inaccessible. Fifteen articles were considered; most highlighted the interplay between the criminal system, homelessness, mental disorders, and ethnic/racial minorities. Five articles highlighted differences in treatment. One stated that African-Americans and Asians were less likely than Whites to have access to mental health services. Concerning treatment for substance use disorders, one study found Hispanic inmates were more often engaged in treatment, followed by Caucasians and lastly, African-Americans; a different study reported the percentage of Whites and Blacks receiving treatment was similar, while Latinos were under-represented. Whites were most likely to have mental health counseling/substance use treatment as part of their sentence. A study from New-Zealand stated that treatment for mental disorders was less common for Maoris, in whom suicidal thoughts were often unrecognized. The last study reported a higher risk of self-harm for foreign patients, coupled with non-recognition/misinterpretation of symptoms.

Conclusions

Racial/ethnic inequalities show that disparities in healthcare are pervasive in all settings. More studies are needed to better understand the complex nature of this problem.

Disclosure

No significant relationships.

Stereospecific in vitro and in vivo effects of the new sinus node inhibitor (+)-S 16257

The effects of the two isomers, (+)-S 16257 and (-)-S 16260, of a new bradycardic agent, (+/-)-S 15544 (7,8-dimethoxy 3-[3-[[(4.5-dimethoxybenzocyclobutan-1-yl)methyl] methylamino]propyl]1,3,4,5-tetrahydro-2H-3-benzazepin-2-one), were compared in vitro and in vivo on cardiac spontaneous rate and repolarization time. In the isolated rabbit sino-atrial node, the three compounds (3 microM) were equi-effective to reduce the action potential firing rate. In anesthetized pigs, both isomers (0.03, 0.1, 0.3 and 1 mg kg(-1) i.v.) were equipotent to reduce heart rate. For all compounds, the negative chronotropic effect resulted from a reduction in the slope of diastolic depolarization of pacemaker cells. In sino-atrial node cells, (-)-S 16260 (3 microM) increased action potential duration while (+)-S 16257 had a smaller effect. In driven guinea-pig papillary muscles exposed to increasing concentrations of compounds (0.1 to 10 microM) a small prolongation of action potential duration was observed. This prolongation was more marked in rabbit Purkinje fibers stimulated at a low rate. In all cardiac preparations the highest prolongation was observed with (-)-S 16260. In vivo, (-)-S 16260 prolonged QTc at the two highest doses tested while (+)-S 16257 had no effect. In conclusion, resolution of (+/-)-S 15544 into its two enantiomers yielded compounds with the same bradycardic effects. Of the isomers, (+)-S 16257 has an increased specificity with minimal direct effect on action potential repolarization.

Functional correlates of dopamine D3 receptor activation in the rat in vivo and their modulation by the selective antagonist, (+)-S 14297: 1. Activation of postsynaptic D3 receptors mediates hypothermia, whereas blockade of D2 receptors elicits prolactin secretion and catalepsy

Using [125I]-iodosulpride as a radioligand, the novel naphthofurane, (+/-)-S 11566 [(+/-)-[7-(N,N-dipropylamino)-5,6,7,8-tetra-hydro- naphtho(2,3b)dihydro,2,3-furane]) showed a marked preference for human, recombinant D3 as compared with D2 receptors stably transfected into Chinese hamster ovary cells (Kis = 24/529 nM). This activity resided in its (+)-eutomer, (+)-S 14297 (13/297 nM) as compared with its (-)-distomer, (-)-S 17777 (406/3544 nM). In contrast, (+)-AJ 76 manifested only a mild 2-fold preference for D3 sites (70/154 nM), whereas haloperidol and six additional antagonists showed a mild (2-7-fold) preference for D2 sites. As concerns agonists, (+)-7-OH-DPAT, (+/-)-CGS 15855A, quinelorane, (-)-quinpirole and N-0434 displayed a preference (6-40-fold) for D3 receptors, whereas piribedil showed a slight, 2-fold, preference for D2 sites (243/126 nM). (+)-S 14297 showed low (> 1.0 microM) affinity at rat D1 and D2 sites and at cloned, human D4 and D5 receptors and only low affinity (145 to > 10,000 nM) at all other sites examined. In vivo, administered s.c., (+)-7-OH-DPAT, CGS 15855A, quinelorane, (-)-quinpirole and N-0434 potently evoked hypothermia. Across all (8) agonists tested, potency correlated significantly with affinity at D3 sites (r = .84, P < .001) but not D2 sites (r = .50, P > .05). (+)-S 14297 (0.16-1.25 mg/kg, s.c.) blocked the induction of hypothermia by (+)-7-OH-DPAT, CGS 15855A and (-)-quinpirole, but not by the alpha 2-adrenergic agonist, clonidine, without influencing core temperature alone. In contrast, (-)-S 17777 (10.0 mg/kg, s.c.) was only partially active. Across all (9) antagonists, potency for inhibition of (+)-7-OH-DPAT-induced hypothermia correlated more strongly with affinity at D3 (r = .96, P < .001) than D2 (r = .75, P < .02) sites. Whereas haloperidol and the other antagonists provoked prolactin secretion and elicited catalepsy, (+)-S 14297 and (+/-)-S 11566 at doses of up to 10.0 and 40.0 mg/kg, s.c., respectively, were not significantly effective (P > .05). Across all antagonists, potency for eliciting prolactin secretion and catalepsy correlated better with affinity at D2 (r = .95 and .96) than D3 (r = .76 and .91) sites. In conclusion, these data demonstrate that the novel naphtofurane, (+)-S 14297, is a selective ligand (antagonist) at dopamine D3 receptors and suggest that their activation mediates hypothermia in the rat.(ABSTRACT TRUNCATED AT 400 WORDS)

Functional correlates of dopamine D3 receptor activation in the rat in vivo and their modulation by the selective antagonist, (+)-S 14297: II. Both D2 and "silent" D3 autoreceptors control synthesis and release in mesolimbic, mesocortical and nigrostriatal pathways

The preferential dopamine (DA) D3 versus D2 receptor agonist, (+)-7-OH-DPAT, dose-dependently decreased DA synthesis in the nucleus accumbens, olfactory tubercles, striatum and frontal cortex. This action was potently mimicked by several other high-potency D3 agonists: CGS 15855A, (-)-quinpirole, quinelorane and N-0434. In contrast, piribedil, which displays a mild preference for D2 sites, was less active. Across eight agonists, potency for inhibition of DA synthesis correlated more potently to affinity at D3 (r = .82 +/- .04) than D2 receptors (r = .60 +/- .06, P < .05). Correlations were also marked to potency for induction of a further D3-mediated response, hypothermia (r = .93 +/- .02). The novel and selective D3 versus D2 antagonist, (+/-)-S 11556, attenuated the action of (+)-7-OH-DPAT in each structure. This action was shared by its active (+)-eutomer, (+)-S 14297, whereas its inactive (-)-distomer, (-)-S 17777, was ineffective. (+)-S 14297 similarly attenuated the inhibitory action of CGS 15855A and (-)-quinpirole upon DA synthesis, whereas it failed to modify inhibition of striatal DA synthesis by the alpha 2-adrenergic receptor agonist, clonidine. As compared with the D2/D3 receptor antagonist, haloperidol, neither (+/-)-S 11566 nor (+)-S 14297 modified DA turnover upon administration alone. Furthermore, across (nine) antagonists, potency in facilitating DA synthesis more powerfully correlated to affinity at D2 (r = .94 +/- .01) than D3 (r = .73 +/- .01) sites (P < .01). Correlations were also marked to potency for induction of catalepsy (r = .91 +/- .01) and prolactin secretion (r = .89 +/- .01) but not for antagonism of (+)-7-OH-DPAT-induced hypothermia (r = .60 +/- .01). In freely moving rats, (+)-7-OH-DPAT dose-dependently reduced dialysate concentrations of DA in the nucleus accumbens and contralateral striatum: this action was potently mimicked by CGS 15855A, but only weakly so by piribedil. (+)-S 14297 markedly attenuated the action of (+)-7-OH-DPAT, whereas (-)-S 17777 was inactive. In contrast, haloperidol completely blocked the action of (+)-7-OH-DPAT. Finally, in distinction to haloperidol, upon administration alone, (+)-S 14297 did not significantly enhance the release of DA. In conclusion, these data suggest that D3 (auto)receptors control synthesis and release of DA in dopaminergic pathways innervating the limbic system, cortex and striatum.(ABSTRACT TRUNCATED AT 400 WORDS)

S 14297, a novel selective ligand at cloned human dopamine D3 receptors, blocks 7-OH-DPAT-induced hypothermia in rats

The selective dopamine D3 receptor agonist, 7-OH-DPAT ((+)-7-hydroxy-2-(di-n-propylamino)tetralin) and the novel naphthofurane, S 14297 ((+)-[7-(N,N-dipropylamino)-5,6,7,8-tetrahydro- naphtho(2,3b)dihydro,2,3-furane]), bound with high affinity and selectivity to recombinant, human dopamine D3 versus D2 receptors stably transfected into Chinese hamster ovary cells: Ki values = 2 versus 103 nM for 7-OH-DPAT and 13 versus 297 nM for S 14297. In contrast, the putative dopamine D3 receptor antagonist, AJ 76 (cis-(+)-5-methoxy-1-methyl-2-(n- propylamino)tetralin), displayed low affinity and selectivity for dopamine D3 versus D2 sites (70 versus 154 nM). 7-OH-DPAT (0.01-0.16 mg/kg s.c.) provoked hypothermia in rats, an action abolished by S 14297 (0.04-0.63 mg/kg s.c.) and, less potently, by AJ 76 (0.16-2.5 mg/kg s.c.). S 14297 (20.0 mg/kg s.c.) did not modify prolactin secretion. These data suggest that dopamine D3 receptors mediate hypothermia in the rat and that S 14297 acts as a selective antagonist at these sites.

Electrophysiological effects of S 16257, a novel sino-atrial node modulator, on rabbit and guinea-pig cardiac preparations: comparison with UL-FS 49

1. S 16257 is a new bradycardic agent. Its electropharmacological profile has been compared to that of the known bradycardic compound UL-FS 49 (Zatebradine). Intracellular recordings of action potentials (APs) were performed with conventional glass microelectrodes. 2. In the rabbit isolated sino-atrial node (SAN) tissue, S 16257 and UL-FS 49 (1 microM, 3 microM and 10 microM) were equipotent in slowing spontaneous APs firing predominantly by decreasing the rate of diastolic depolarization (at 3 microM, -23.8 +/- 3.9% and -27.9 +/- 2.6%, respectively). For the two compounds a maximal effect was obtained at 3 microM. In these preparations, action potential duration at 50% of total repolarization (APD50) was more affected by UL-FS 49 than S 16257 at any concentration tested (at 3 microM, +8.9 +/- 2.9% and +29.1 +/- 3.7% for S 16257 and UL-FS 49, respectively; P < or = 0.01). 3. To estimate the direct effects on AP duration, driven cardiac preparations were exposed to these agents. In guinea-pig papillary muscles, paced at a frequency of 1 Hz, increasing concentrations of S 16257 or UL-FS 49 (0.1 to 10 microM, 30 min exposure for each concentration) slightly prolonged AP repolarization. This prolongation was more marked for UL-FS 49 (at 1 microM, +6.1 +/- 0.6% and +11.2 +/- 1.3% elevation of APD50, for S 16257 and UL-FS 49, respectively). 4. Application of UL-FS 49 (3 microM) to rabbit Purkinje fibres, triggered at a frequency of 0.25 Hz, induced a marked prolongation of APD50 and APD90 (+149.4 +/- 51.2% and +86.0 +/- 15.4%, respectively). S 16257 (3 MicroM) induced only a weak prolongation of AP (+ 14.1 +/- 5.0% and + 14.8 +/- 3.3% for APD50 and APD90, respectively) significantly smaller than in the case of UL-FS 49.5. These results show that S 16257 slows the rate of spontaneous AP firing in isolated SAN mainly by a reduction of the diastolic depolarization of the cells, which suggests an inhibition of the pace-maker current (If). S 16257 and UL-FS 49 are equipotent in their bradycardic effect but S 16257 is more specific as it induces less increase in myocardial repolarization time.

Analysis of nurse-doctorates; data collected for the International Directory of Nurses with Doctoral Degrees

In an American Nurses' Foundation survey of the 1973 population of nurses with doctoral degrees (N = 1,020) general trends in doctoral education of nurses were elicited. Specific unique characteristics were highlighted, including: a continuing trend for nurses to earn the Ph.D. rather than the Ed.D., a divergence between field of doctoral study and the current field of research interest, and a slight number of these qualified nurses actually participating in research of any kind. The majority of subjects were single; most were employed in a university or college where they held either full or associate professorships; most considered themselves still to be in the field of nursing, although their doctoral studies frequently took them out of the discipline; their work responsibilities were heavily loaded with administrative duties. As compared with the holders of doctoral degrees in other fields, nurses earned their degrees later, but took no longer to complete them. While universities in the Mid-Atlantic states were the largest producers of nurse-doctorates, universities in the Midwest were found to be the most frequent employers. Questions regarding the future direction of nurse-doctorates were raised.